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Event Notification Report for June 29, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/28/2007 - 06/29/2007

** EVENT NUMBERS **


43422 43443 43449 43453 43455 43456 43457 43458

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other Event Number: 43422
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: IOWA HEALTH - DES MOINES
Region: 3
City: DES MOINES State: IA
County:
License #: 0077-1-77-M1
Agreement: Y
Docket:
NRC Notified By: RANDY DAHLIN
HQ OPS Officer: JOE O'HARA
Notification Date: 06/14/2007
Notification Time: 14:54 [ET]
Event Date: 06/14/2007
Event Time: 10:30 [CDT]
Last Update Date: 06/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL PERSONNEL OVEREXPOSURE

The licensee's RSO received a phone call from Landauer at 1030 this morning to report a badge which had a deep dose reading of 6437 milliRem, an eye dose reading of 6437 milliRem, and a shallow dose reading of 6400 milliRem. The badge was assigned to the Chief of Surgery for the licensee for the month of January 2006. The RSO is investigating the cause for the fifteen month delay (January 2006 till June 2007) in processing the badge. Landauer told the RSO that this was a "dynamic" exposure to the badge meaning that the badge was moving during the time period of exposure.

Iowa Item Number IA-070001.

* * * RETRACTION PROVIDED BY RANDY DAHLIN TO KOZAL ON 6/28/07 AT 0847 * * *

Upon further investigation of it was determined that the exposure is solely due to fluoroscopic procedures. Radiation generated from fluoroscopic equipment is not regulated by the NRC. Due to this fact the event should not have been reported to the NRC and is retracted. The State of Iowa will continue to investigate this matter with its licensee.

Notified R3DO (Louden) and FSME EO (Flannery).

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General Information or Other Event Number: 43443
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: UNKNOWN
Region: 1
City: TROY State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/25/2007
Notification Time: 16:45 [ET]
Event Date: 06/19/2007
Event Time: [EDT]
Last Update Date: 06/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1)
JACK DAVIS (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING HIGHER THAN PRESCRIBED DOSE DELIVERED

The following notification was received from the State of NY Bureau of Environmental Radiation Protection via fax:

"AS Agency -New York State Department of Health

"Event Report - ID # NYS DOH 07-002

"Licensee Name and License Number - Withheld as per NYS Law

"Event Date - June 19, 2007

"Event Type - Medical Event

"Event Description:

"A medical event involving yttriurn-90 Zevalin (Ibritumomab Tiuxetan) for treatment of non-Hodgkin's lymphoma was reported to NYS DOH by telephone on June 22, 2007. The authorized physician user (AU) approved a dosage of 29 mCi for treatment on June 19, 2007, however a dose of 36.7 mCi was administered.

"This Zevalin patient (A) was scheduled to receive treatment at the hospital on June 19, 2007. The radiopharmacy prepared the dose but observed that the assay from the supplier was approximately 10 mCi higher than their assay. They reviewed their data including their most recent calibration of the dose calibrator with a NIST traceable syringe standard. They decided to use their NIST traceable calibration factor and associated assay. The dose was dispensed and the patient was treated.

"Another Zevalin patient (B) was scheduled for treatment on June 20, 2007. In preparing patient B's dose the radiopharmacy observed the same condition as with patient A's assay. At this point they realized they had a problem and patient B's dose was not dispensed. An investigation began.

"The radiopharmacy identified the error. They used an AEA Technology QSA Inc. model SIM.SY2 (Sealed Source Registry No. MA-1059-S-360-S) to calibrate their Capintec CRC-15R dose calibrator as well as the hospital's dose calibrator. This source is specifically designed to calibrate Capintec CRC-15R units for yttrium 90 assays. The calibration source label has an assay of 20mCi (740 MBq) of strontium 90/ytrrium 90 and a calibration date of Nov. 14, 2004. However, the source certificate lists the yttrium 90 'Equivalent Activity' as 30.68 mCi (1135 MBq), which is the value that should have been used for the calibration. Apparently the certificate was not available (misplaced?) on June 8 &10 for the calibration. The radiopharmacy used the decay-corrected value from the label rather than a decay-corrected value of the certificate's 'Equivalent Activity'. Since the same calibration error was performed on the hospital's dose calibrator, the hospital's assay matched up with that of the radiopharmacy and with the intended dosage.

"The patient's daughter and the referring physician were notified on the day after discovery. The treating physician is assessing situation and the possible effects to the patient.

"Intended dose - 29 mCi
"Delivered dose - 37.6 mCi
"Date of treatment - 6/20/07
"Date of error discovered - 6/20/07
"Isotope/drug - yttrium-90/Zevalin
"Reported/notification dates:
"Patient/patient rep. - 6/20/07
"Referring MD - 6/20/07
"NYS DOH - 6/22/07
"Cause: Dose calibrator calibration error
"Effect - patient's condition and effects are being assessed
"Investigation - RCA required
"Initial Written report due 6/29/07"

* * * UPDATE AT 1107 EDT ON 6/26/07 FROM FSME (FLANNERY) TO JASON KOZAL VIA EMAIL * * *

"This event (EN43443) has been reviewed and determined to be a reportable medical event."

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Power Reactor Event Number: 43449
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RANDALL RAHRIG
HQ OPS Officer: JASON KOZAL
Notification Date: 06/27/2007
Notification Time: 11:34 [ET]
Event Date: 06/27/2007
Event Time: 09:21 [CDT]
Last Update Date: 06/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMNES CAMERON (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

REACTOR TRIP DUE TO OFF-SITE POWER FLUCTUATION

"Switchyard line 2001 tripped and re-energized during a thunderstorm. This caused main generator output breaker, ACB 3-4, to trip open. At this time '1D' reactor coolant pump (RCP) tripped and caused a reactor trip. Cause for the '1D' RCP trip is under investigation.

"The heat sink is being provided by Aux Feedwater and the use of Steam Dumps. Electrical power is being provided by offsite power."

All rods inserted. There were no complications during the trip and all systems functioned as required. Offsite power remained available throughout the transient. The electrical transient had no impact on Unit 2.

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 2217 EDT ON 6/28/07 FROM B. SHEAR TO W. HUFFMAN * * *

"This is a revision to a previously transmitted ENS call on 6/27/07 EN# 43449.

"Braidwood Unit 1 Reactor automatically tripped on a loss of '1D' RCP greater than P-8 setpoint. The cause of the RCP trip was an electrical disturbance during a thunderstorm.

"The reactor trip automatically caused a main turbine and generator trip. Auxiliary feedwater system automatically started on the low-2 S/G water level that is expected from a full power reactor trip. Auxiliary feedwater and main steam dumps are providing a heat sink.

"A switchyard line also tripped during this electrical transient causing multiple switchyard breakers to open. Electrical power is being provided by offsite power.

"All control rods fully inserted. There were no complications during the trip and all systems functioned as required. Offsite power remained available throughout the transient. The electrical disturbance had no impact on Unit 2.

"The licensee notified the NRC resident inspector." R3DO (Louden) notified.

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Power Reactor Event Number: 43453
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TIM PAGE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/27/2007
Notification Time: 15:20 [ET]
Event Date: 06/27/2007
Event Time: 10:15 [EDT]
Last Update Date: 06/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY POWELL (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF COMMUNICATIONS CAPABILITY AT EOF

"At approximately 1015 On June 27, 2007, with the James A. Fitzpatrick (JAF) Nuclear Power Plant operating at 100% reactor power, a loss of phone service occurred in the Emergency Operations Facility (EOF) and Joint information Center (JIC).

"Discussions with the Oswego County 911 Center (only county within the 10 mile EPZ) determined that phone service in the service area was lost at approximately 1015 hours on June 27,2007. Most telephone and data capability at the EOF and JIC are out of service at this time. Cellular arid satellite phone backups are available at the EOF and JIC. The primary and backup means to notify federal, state and local agencies from JAF are unaffected and have been tested and are operational. The Emergency Response Organization (ERO) notification system is unaffected and has been confirmed to be operational. Sirens and tone alert systems are unaffected.

"This loss of phone service is considered to be a major loss of offsite communications capability and is therefore reportable as an eight (8) hour telephone notification under 10 CFR 50.72(b)(3)(xiii).

"Repairs are in progress.

"The NRC resident inspector has been briefed and the New York State PSC will be notified."


See related Event #43451.


* * * UPDATE AT 1242 EDT ON 6/28/07 FROM PAGE TO HUFFMAN * * *

"Phone service has been repaired, tested and restored to the EOF and JIC. The NRC Resident and New York State PSC have been informed.
R1DO (Powell) notified.

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Power Reactor Event Number: 43455
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ROBERT MCLAUGHLIN
HQ OPS Officer: JASON KOZAL
Notification Date: 06/28/2007
Notification Time: 10:56 [ET]
Event Date: 06/28/2007
Event Time: 09:55 [EDT]
Last Update Date: 06/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY POWELL (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF GREATER THAN 25% OF THE EPZ SIRENS FOR GREATER THAN 1 HOUR

"This eight hour notification is being made per 10 CFR 50.72(b)(3)(xiii) to report a loss of >25% of the EPZ sirens for greater than one hour. 44 of 165 offsite sirens are not functioning due to loss of power/equipment problems because of a recent storm. Efforts are in progress to restore the affected sirens.

"At 1000 6/28/07 less than 25% of sirens are unavailable."

The licensee notified the NRC Resident Inspector, the State of Pennsylvania, and local governments.

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Fuel Cycle Facility Event Number: 43456
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: LARRY PARSCALE
HQ OPS Officer: JOHN KNOKE
Notification Date: 06/28/2007
Notification Time: 12:18 [ET]
Event Date: 06/27/2007
Event Time: 13:50 [CDT]
Last Update Date: 06/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
DAVID AYRES (R2)
CINDY FLANNERY (FSME)

Event Text

MEDICAL TREATMENT WITH CONTAMINATION

"On June 27, 2007 a Honeywell employee sustained multiple contusions and abrasions to his head, face, and body as a result from a fall from the permanently installed man-lift device. The incident occurred at 1350 at the Honeywell Specialty Materials facility (Feeds Material Building) in Metropolis, IL. The employee was transported to the local medical facility with measurable levels of natural uranium contamination of 5,000 dpm/100 cm on his clothing and skin.

"Honeywell Health Physics personnel accompanied the injured employee to the hospital where they provided contamination control recommendations to the attending medical staff. No contamination was detected on hospital facilities, equipment or staff following the treatment of the injured employee.

"Following decontamination of the injured employee survey results were less than 1,000 dpm/100 cm.

"All contaminated materials from the injured employee's decontamination and treatment were collected and returned to the Honeywell Specialty Materials site."

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Power Reactor Event Number: 43457
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MIKE FERRY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/28/2007
Notification Time: 21:53 [ET]
Event Date: 06/28/2007
Event Time: 17:17 [PDT]
Last Update Date: 06/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
GREG PICK (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 70 Power Operation 0 Hot Shutdown

Event Text

REACTOR TRIP DUE TO CONDENSATE PUMP TRIP

"Reactor trip at 1717 hrs PDT due to [condensate pump] COND-P-2B trip. Reactor power was at 70% with [condensate pump] COND-P-2A secured. Reactor vessel level reached -50 inches and was restored with High Pressure Core Spray and Reactor Core Isolation Cooling. Main Steam Isolation Valves closed as expected due to the reaching -50 inches. All systems operated as expected. Further investigation into COND-P-2B trip is underway. Plant is stable in mode three, heat removal is being maintained by RHR-P-2B and Safety Relief Valves."

All rods fully inserted on the automatic reactor scram. All safety systems were available at the time of the trip. The trip was considered uncomplicated. The reactor pressure is currently being maintained between 500 to 600 psi and water level between 60 to 80 inches. The licensee was at 70% power at the time of the trip due to maintenance of condensate pump P-2A.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 43458
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAVE HELD
HQ OPS Officer: PETE SNYDER
Notification Date: 06/29/2007
Notification Time: 00:20 [ET]
Event Date: 06/29/2007
Event Time: 00:14 [EDT]
Last Update Date: 06/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RAY POWELL (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

RADIATION MONITORING INFORMATION TO ERDS AND SPDS WILL BE UNAVAILABLE DURING PLANNED UPGRADE TO THE SYSTEM.


"The computer servers which supply radiation monitoring information to the ERDS (Emergency Response Data System) and SPDS (Safety Parameter Display System) systems will be taken out of service to implement a planned upgrade. The servers are being replaced with upgraded models and are expected to be out of service for approximately 4 to 8 hours. The ability of radiation monitors to alarm in the control room will be unavailable while the servers are being replaced. The in plant radiation monitoring skids will be unaffected, as will any automatic actions generated by the monitors. The safety related radiation monitor displays in the control room will also remain available. As a compensatory measure while both servers are unavailable, a dedicated radiation protection technician will monitor the in plant radiation monitor skids to update the control room if anomalous indications are observed. In addition, operations will record the safety related radiation monitor readings every 2 hours.

"This is an 8 hour reportable event per 10CFR50.72(b)(3)(xiii), Major Loss of Assessment Capability. The operations of BVPS Unit 2 plant systems is not affected by this planned action. BVPS Unit 1 is not affected by this planned action.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012